Triptans lead option for migraine

OTCs also effective

Migraine headaches are common—occurring in about 11 out of 100 people. They tend to start between the ages of 10 and 46, and occur more often in women than men.

Migraine headaches can be incapacitating, including pain and symptoms such as nausea, vomiting, or sensitivity to light. Many people experience a throbbing pain on only one side of the head. Some migraine patients experience warning symptoms, called an aura, before the actual headache begins. Some migraine attacks are triggered by stress, lack of food or sleep, exposure to bright lights, certain odors, or (in women) hormonal changes.

Scientists used to believe migraines were linked to the opening and narrowing of blood vessels in the head. Now they believe the cause is related to genes that control the activity of certain brain cells.

Several different classes of medications can help prevent migraine attacks or relieve symptoms of attacks when they occur. An over-the-counter pain reliever such as aspirin, acetaminophen or ibuprofen may be effective in treating mild to moderate migraine. They are also marketed in combinations with caffeine and other medicines.

"A triptan is the drug of choice for treatment of moderate to severe migraine headache," says Mark Abramowicz, MD, editor in chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "Oral ergot preparations cost less than the triptans, but are not as effective and are associated with more adverse events."

Short-acting oral triptans are similar in efficacy and speed of onset; some patients may respond to one triptan and not to another. Use early in an attack, when pain is mild to moderate, has been shown to improve outcomes.

"The nasal spray forms of sumatriptan and zolmitriptan have a faster onset of action than all the oral triptans, and probably deserve wider use," Dr. Abramowicz says. "Subcutaneous sumatriptan is expensive, but it is the fastest acting and most effective triptan formulation."

Overuse (two or more days per week, for more than three months) of OTC medications, ergot medications or triptans can lead to medication-overuse headache. To prevent this, restrict the use of these drugs per attack, per week, and per month, Dr. Abramowicz says.

To prevent migraine attacks, the antiepileptics Depakote (valproate) and Topamax (topiramate) are increasingly used, but there is no evidence that they are more effective than beta-blockers, which cost much less. The side effects of beta-blockers can include fatigue, depression, and orthostatic hypotension. Side effects of anti-epileptics include nausea, fatigue and weight gain.

EDUCATIONAL GROUP SESSIONS

Physicians in the Kaiser Permanente Southern California region have found that group-based interventions for migraine patients lead to better outcomes, as well as lower overall costs for the MCO. In a study reported in 2003, small groups of migraine patients (264 total) attended an educational session led by a nurse practitioner, with follow-up consultations. Participants experienced a 49% reduction in headache-related ER visits and a 32% reduction in clinic visits. There was a 19% increase in pharmacy costs for the group as a whole ($5,423) but overall healthcare costs were reduced by $18,757 despite increased triptan costs.

Although these sessions were led by a nurse practitioner, continuing Kaiser programs for migraine patients also could be led by a physician or a neurologist. It turns out the most important benefit of these sessions is the way they increase the patient's sense of self-efficacy.

"We found how much they learn isn't the main factor," says Morris Maizels, MD, a family physician at the Kaiser Permanente Woodland Hills Medical Center, and the lead author of the study. "Most importantly, patients feel empowered after the group experience. They have the sense that 'I'm going to take control of this situation, rather than letting it control me.'"

Dr. Maizels estimates that if the study were repeated today, pharmacy costs would go up modestly, but the overall savings would go up dramatically.

Migraine tends to be underdiagnosed and undertreated, he says. One reason is that once a patient has been diagnosed with another condition, such as sinus headaches or tension headaches, physicians often accept the diagnosis instead of doing their own evaluation.

In addition, people may have a perception of migraine as a horrible condition, when, in reality it can take a much milder form.

This article is based on information supplied by The Medical Letter (
http://www.medicalletter.org/),
a non-profit organization that publishes newsletters offering critical appraisals of new drugs and comparative reviews of older drugs. The Medical Letter is completely independent of the pharmaceutical industry. It is supported entirely by subscription sales and accepts no advertising, grants or donations. Institutional site license inquiries can be sent to info@medicalletter.org.